Abstract
Background and aim
In 2018, the country of Georgia legalized cannabis for recreational use and decriminalized limited possession. This study aimed to assess whether cannabis use increased among young adults (ages 18–29 years) in Georgia after national policy changes and to evaluate whether perceived access became easier after legalization and current risk factors of young adult cannabis use.
Methods
We used data from the Georgian nationally representative survey administered in 2015 (n = 1308) and 2022 (n = 758), before and after decriminalization. We performed appropriate bivariate analyses and multivariable linear and logistic regressions to assess the following: legalization's impact on cannabis use; perceived difficulty to obtain cannabis; age of first use; differences in use between females and males; and factors associated with current use.
Findings
Among young adults lifetime prevalence of cannabis use was similar in 2015 (17.3%) and 2022 (18.1%) [Odds Ratio (95% confidence interval) = 1.1 [0.7, 1.6], P = 0.726). Annual prevalence (7% in 2015 vs 7.7% in 2022) was also similar (1.1 [0.7, 2.0], P = 0.650). In 2022 it was less difficult to obtain cannabis than in 2015 (0.5 [0.4, 0.8], P = 0.021). The age of first use increased statistically significantly (18.1 years in 2015 vs 19.1 in 2022, P = 0.003).
In 2022, annual prevalence of use was lower among females (1.9% vs 13.1%; OR = 0.1 [0.0, 0.3], P < 0.0001) and higher among those who gambled (11.7% vs 4.4%; OR = 3.2 [1.5, 6.8], P < 0.003). Males initiated cannabis use at an earlier age (19.1 years vs 20.6 for females, P = 0.03), and could obtain cannabis easier than females (P < 0.0001).
Conclusion
There was a minimal shift of cannabis use in young adults following implementation of recreational cannabis use legalization in Georgia. Males and people who gambled were at higher risk of cannabis use.
Keywords: cannabis, decriminalization, Georgia, legalization, policy, prevalence, young adults, youth
INTRODUCTION
According to the World Drug Report 2023, cannabis is one of the most widely used drugs, with an estimated 219 million users globally in 2021. It is also the most used drug among young people. Globally, in 2021, those aged between 15 and 16 years had an annual prevalence of cannabis use of 5.3%, compared to 4.3% for adults age 18 and older. In Europe, annual prevalence of cannabis use among those 15 to 16 years old was over 11%—twice that reported among the people 16 to 64 years old [1]. In the United States, cannabis use among young adults (age 19–22) reached a historically high level in 2021, with 42.6% reporting use in the past year [2].
Although recreational cannabis use is often perceived as harmless, up to 10% of users develop cannabis use disorder (CUD), with people who start using cannabis at an earlier age being at higher risk of developing CUD and other problems in adulthood [2, 3, 4]. Cannabis use, in particular initiated at an early age, has been reported to have numerous long‐term health and psychosocial consequences (e.g. irreversible cognitive impairment; adverse mental health outcomes such as psychosis, depression and suicidality; brain development alteration; increased risk of motor vehicle accidents; poor academic performance and lower educational attainment; and lower income) [5, 6, 7, 8]. These health and psychosocial effects can be seen in both CUD and the more common non‐disorder cannabis use (NDCU) (i.e. cannabis use not fulfilling disorder criteria) [8].
The main rationale for legalizing recreational use of cannabis has been based on the following arguments: legalization will reduce related crime and remove illicit market; control production (and therefore, content) and retail of cannabis products, resulting in protection of users (youth in particular) from related harm and ability to tax and receive revenue from the sales. Some of the other pro‐legalization arguments are that criminal offense records cause more harm to the users than cannabis use itself; and that cannabis use has less adverse effects compared to other illicit drugs [9, 10, 11, 12, 13]. As of 2023, only a few countries and territories have legalized or decriminalized recreational cannabis use, but more countries are expected to do so in the years ahead. Models of legalization and decriminalization vary by legality of use, legality of growing cannabis for own use or also for gifting to others and sales. Production licensing and retail regulations also vary [11].
Georgia, a relatively socially conservative Eastern European country of 3.7 million people located in the South Caucasus, has traditionally had strict substance use policies and an underdeveloped drug monitoring system (for valid, continuous data) [14]. Following a series of constitutional court rulings in 2015 to 2018 [15, 16, 17, 18], the Georgian parliament gradually amended the laws effectively legalizing cannabis consumption for non‐medical recreational use and decriminalizing limited possession (up to 10 g) in 2018. At that time, Georgia became the second country after Uruguay to legalize cannabis use, and currently, Georgia remains the only post‐Soviet country to do so. Unlike Uruguay, distribution in any way (including retail) of cannabis remains illegal in Georgia as of 2024. As distribution and sale remain illegal, a small‐scale survey reported that receiving cannabis for free from friends was a common way of obtaining cannabis [19]. Smoking cannabis in public spaces or in places of gathering of children remains legally restricted. Growing cannabis is also illegal, although the law has no sanctions defined for growing. Cannabis use by persons younger than 21 remains illegal [20, 21]. These legal changes led to a reallocation of police priorities, making cannabis use less of a concern. Consequently, the annual number of administrative charges for illicit drug use dropped nearly threefold, from 13 555 cases in 2019 to 5126 cases in 2022 [22]. Most of these cases involved cannabis use.
Before legalization, in 2015, ~16% of adults in Georgia had tried cannabis at least once in their lifetime [23]. The European School Survey Project on Alcohol and Other Drugs reported in 2019 that, in Georgia, 14% of students who turned 16 during the year of the survey (2019) had tried cannabis products at least once in their lives [24]. A late 2019 online survey of regular cannabis users reported that the policy change did not influence frequency of use among people with a longer history of cannabis use, but relatively new users said that frequency of use increased. The same study found that although the availability and mode of supply of cannabis remained unchanged for the majority of respondents, more users started growing cannabis [25].
Effects and impact of recreational cannabis legalization and decriminalization on societies is a topic of global relevance and increasing scientific interest. Despite a rapidly growing body of published evidence, findings remain mostly mixed [10, 26, 27, 28, 29, 30, 31, 32] with little attention given to young adults. A central public health and political concern is about harms for vulnerable groups like young adults (ages 18–29 years). Young adulthood is a transition phase in human lives characterized by increased autonomy, decreased parental supervision and substance use experimentation [33, 34]. Studies from Canada, where cannabis was legalized for recreational use and retail in 2018, report mixed results on youth (age 15–24) pre‐ and post‐ legalization of cannabis use [13]. A study from Washington State reported an increase of cannabis use among youth [18‐25] between 2014 and 2019, following legalization in 2012 [35]. Therefore, more studies from diverse environments are needed to measure cannabis use changes, particularly in such high‐risk groups as young adults. As of 2023, no cannabis use studies from Georgia used a population representative sample. Additionally, previous Georgian cannabis studies did not focus on young adults. This study aimed to assess whether cannabis use increased among young adults (ages 18–29 years) after policy changes in Georgia. Further, we evaluated risk factors of youth cannabis use and whether perceived access became easier after legalization.
METHODS
Design and setting
We used data from two waves of the nationally representative General Population Survey administered in Georgia in 2015 and 2022 (3 years before and 4 years after decriminalization in 2018). This survey provides information on key indicators of drug use designed by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) [23, 36].
This population‐representative survey used a stratified, multistage cluster sampling design. Data were collected in all 11 geographic regions of Georgia, including the capital city of Tbilisi. The original survey waves collected data from individuals age 18 to 64 years. In our analysis, we considered data for young adults (18–29 years). The numbers of respondents in this age category in 2015 and 2022 were 1359 and 762, respectively. The difference in number of respondents between the survey waves was because of planned oversampling of the 18 to 29 age category in the 2015 survey wave, because a lower response rate was expected in this age group. This technique was not repeated in the 2022 wave. Details on the sampling methods and data collection are available in the survey reports published in 2016 and 2023 [36, 37].
The data were collected using a modified and adapted questionnaire based on the EMCDDA's European Model Questionnaire (EMQ). The General Population Survey 2015 questionnaire was fully reviewed by a survey working group of local researchers and EMCDDA experts. For the variables examined in this article, the questionnaires from 2015 and 2022 use the same or, in some cases, comparable questions and are available in the Data S1.
Variables
The main outcome variables for our analysis were the following: lifetime, last 12‐month and last 30‐day prevalence of cannabis use (yes/no); and frequency of use (number of days a respondent used cannabis in the last 30 days). Other participant characteristics surveyed included: age of first use of cannabis; perception of difficulty to obtain cannabis within 24 hours (impossible, very difficult, quite difficult, quite easy and very easy, which were re‐categorized as impossible, difficult and easy).
The main exposure variable was the survey year (2015 or 2022). Other covariates considered in this study were: sex (male, female); age (in years); education (primary/secondary, higher); occupation (employed, unemployed, student, pensioner [including retirement plans and social financial support]); monthly income (≤500 Georgian Lari [GEL], >500 GEL, approximately USD$200 in 2015, USD$180 in 2022); alcohol use frequency (less frequently than once a month or never, once a month, 2–4 times a month, 2 or more times a week); and lifetime, 12‐month and 30‐day prevalence of gambling (yes/no; defined as involvement in different types of games such as slot machines, online slot machines, casino games, cards tournaments, sports and non‐sports betting, online betting, lotteries [purchased by respondent] and private betting). We also assessed the following characteristics: tobacco use (yes/no); and history of use of illegal drugs (any use of the following: new psychoactive substances, inhalant, ecstasy, lysergic acid diethylamide, cocaine, amphetamine/methamphetamine, homemade stimulants, 1 heroin, opium, other opiates/analgesics, methadone, buprenorphine [yes/no]).
Statistical methods
All analyses were conducted on complete data among the young adults (18–29 years) in SAS 9.4 (SAS Institute) and SUDAAN 11.0.4 (Research Triangle Park). Analyses accounted for the complex survey design and used weights to obtain estimates for the target population, controlling for the sample coming from different regions of the country. We obtained summary statistics (proportions, means and SE) for all variables described above. We conducted bivariate analyses to test the significance of the distribution of all variables between the years with two‐sided χ2 (categorical variables) or the Wald F (continuous variables) tests. We conducted similar bivariate analyses as described above to evaluate the association of the characteristics with the outcomes. We used the Benjamini and Hochberg's (BH) control for the false discovery rate approach to adjust for the multiple comparisons [38]. This was applied as follows: for each of the outcomes considered, the P‐values were sorted in an ascending order. For each test, if the obtained P‐value ≤0.05 × (i/n), where (i = 1 to n), then it was considered statistically significant.
Further, we obtained least squares means (or model‐adjusted means) with 95% CI from multivariable linear regressions for continuous outcome (age at first use) and OR with 95% CI and adjusted percentages with 95% CI from multivariable logistic (dichotomous outcomes, lifetime and annual prevalence of use of cannabis) and multinomial generalized logistic regression (outcome with three categories, perceived difficulty to obtain cannabis within 24 hours). In the regression models, we included only those variables that were considered important contextually and with low missing values (age, sex, education, occupation, monthly income, alcohol use and gambling).
Further, we fit similar regressions to evaluate the factors associated with age at first use of cannabis and cannabis use ever and in the past 12 months based on the data collected in 2022. We considered two‐sided P < 0.05 as statistically significant.
Most of the variables included in the analysis had <2% missing data. We only included variables in the analysis with ≤10% missing values.
The research questions and the analysis plan were not pre‐registered on a publicly available platform, and the results should, therefore, be considered exploratory.
Ethics
The original survey's aims and objectives, informed consent forms and questionnaires were reviewed and approved by the Ethical Committee of Ilia State University in 2022 and by the Institutional Review Board of the Health Research Union (Tbilisi, Georgia) in 2015. Study participation was voluntary and anonymous. No incentive for participation was given. All participants provided signed informed consent.
The Ethics Committee of David Tvildiani Medical University (DTMU) reviewed background, aims and methods of the analysis presented in this manuscript. The DTMU Ethics Committee exempted this study from ethics committee oversight because the analysis was conducted on completely de‐identified data.
RESULTS
Demographic characteristics
Of the 2066 respondents from both survey waves, 1090 (49.6%) were female and 972 (50.4%) were male, with a mean (SE) age of 23.7 years (0.1) in 2015 and 23.6 (0.1) in 2022. Details on demographic characteristics are presented in Table 1.
TABLE 1.
Demographic characteristics of the Georgian young adults (18–29 years old) participating in the general population survey in 2015 and 2022.
| Characteristics | Overall (n = 2066) | 2015 (n = 1308) | 2022 (n = 758) | P‐value a | ||
|---|---|---|---|---|---|---|
| n b | n | % (SE) | n | % (SE) | ||
| Sex | 0.203 | |||||
| Female | 1090 | 675 | 49.6 (1.6) | 415 | 46.4 (1.8) | |
| Male | 972 | 629 | 50.4 (1.6) | 343 | 53.6 (1.8) | |
| Education | 0.518 | |||||
| Primary/secondary | 1392 | 892 | 67.1 (1.5) | 500 | 68.6 (1.7) | |
| Higher | 671 | 413 | 32.9 (1.5) | 258 | 31.4 (1.7) | |
| Occupation | 0.066 | |||||
| Employed/self‐employed | 827 | 510 | 41.6 (1.6) | 317 | 43.4 (1.8) | |
| Student | 455 | 326 | 22.7 (1.3) | 129 | 18.1 (1.4) | |
| Unemployed/pensioner or social support | 784 | 472 | 35.8 (1.6) | 312 | 38.5 (1.8) | |
| Net monthly income | <0.0001* | |||||
| ≤500 GEL c | 1520 | 1072 | 82.9 (1.2) | 448 | 63.2 (1.9) | |
| >500 GEL | 442 | 205 | 17.1 (1.2) | 237 | 36.8 (1.9) | |
| Mean (SE) | Mean (SE) | |||||
| Age (y) | 2066 | 1308 | 23.7 (0.1) | 758 | 23.6 (0.1) | 0.655 |
Based on two‐sided χ2 (categorical variables) or Wald F (continuous age) tests. Benjamini and Hochberg's (BH) control for the false discovery rate approach was used to adjust for the multiple comparisons [38]. This was applied as follows: for each of the outcomes considered, the P‐values were sorted in an ascending order. For each test, if the obtained P‐value ≤0.05 × (i/n), where (i = 1 to n; n = 6), then it was considered statistically significant. For example, the first test was considered statistically significant if obtained P ≤ (0.05 × 1/6) or P ≤ 0.008.
All sample sizes are unweighted and might not add to the total because of missing observations; proportions, means and SE are weighted.
500 GEL nominally equaled approximately USD$200 in 2015 and USD$180 in 2022.
P < 0.05.
Bivariate analysis results showed that mean age (SE) of those who reported they had ever used cannabis (24.2; 0.3 years) was significantly higher (P = 0.026) than among those who never tried cannabis (23.6; 0.1 years).
Cannabis use and perceived difficulty to obtain cannabis within 24 hours
The bivariate analysis (presented in Table 2) indicated that lifetime prevalence (± SE) of cannabis use increased from 15.8% ± 1.2% in 2015 to 21.6% ± 1.6% in 2022 (P = 0.004), a 5.8% (95% CI = 1.9, 9.7) increase over this period. Prevalence of use in the last 12 months and in the last 30 days increased, although not statistically significantly.
TABLE 2.
Bivariate analysis of cannabis use, other substance use and relevant behavior by survey year among Georgian young adults (18–29 years).
| Survey year | P‐value a | |||||
|---|---|---|---|---|---|---|
| 2015 (n = 1308) | 2022 (n = 758) | Change in prevalence (2022–2015) | ||||
| n b | % (SE) | n b | % (SE) | % (95% CI c ) | ||
| Have you ever used cannabis? | 0.004* | |||||
| Yes | 190 | 15.8 (1.2) | 143 | 21.6 (1.6) | 5.8 (1.9, 9.7) | |
| No | 1111 | 84.2 (1.2) | 613 | 78.4 (1.6) | ||
| Used cannabis in the last 12 months | 0.083 | |||||
| Yes | 74 | 6.2 (0.8) | 56 | 8.5 (1.1) | 2.3 (−0.3, 5.0) | |
| No | 1199 | 93.8 (0.8) | 702 | 91.5 (1.1) | ||
| Used cannabis in last 30 days | 0.114 | |||||
| Yes | 28 | 2.6 (0.6) | 26 | 4.1 (0.8) | 1.5 (−0.4, 3.4) | |
| No | 1165 | 97.4 (0.6) | 732 | 95.9 (0.8) | ||
| Perceived difficulty to obtain within 24 hours | 0.014* | |||||
| Impossible | 480 | 51.5 (2.0) | 335 | 49.1 (2.0) | −2.4 (−7.9, 3.1) | |
| Difficult | 216 | 23.5 (1.7) | 115 | 18.8 (1.6) | −4.6 (−9.1, ‐0.1) | |
| Easy | 207 | 25.0 (1.7) | 197 | 32.1 (1.9) | ||
| Ever used any illegal substance | 0.001* | |||||
| Yes | 105 | 10.4 (1.2) | 39 | 5.7 (0.9) | −4.7 (−7.6, 1.9) | |
| No | 1069 | 89.6 (1.2) | 708 | 94.3 (0.9) | ||
| Used any illegal substance in the last 12 months | <0.001* | |||||
| Yes | 71 | 7.3 (1) | 19 | 2.8 (0.6) | −4.5 (−6.8, −2.1) | |
| No | 1095 | 92.7 (1) | 730 | 97.2 (0.6) | ||
| Used any illegal substance in the last 30 days | 0.013* | |||||
| Yes | 34 | 3.6 (0.7) | 11 | 1.5 (0.5) | −2.1 (−43.7, −0.5) | |
| No | 1105 | 96.4 (0.7) | 744 | 98.5 (0.5) | ||
| Current tobacco smoker | 0.652 | |||||
| Yes | 386 | 31.4 (1.5) | 204 | 30.4 (1.8) | −1.0 (−5.6, 3.5) | |
| No | 920 | 68.6 (1.5) | 554 | 69.6 (1.8) | ||
| Ever gambled in life | <0.0001* | |||||
| Yes | 397 | 32.0 (1.5) | 342 | 47.4 (1.8) | 15.4 (10.7, 20.1) | |
| No | 898 | 68.0 (1.5) | 405 | 52.6 (1.8) | ||
| Gambled in the last 12 months | 0.034 | |||||
| Yes | 246 | 19.9 (1.3) | 173 | 24.4 (1.6) | 4.5 (0.4, 8.6) | |
| No | 1009 | 80.1 (1.3) | 582 | 75.6 (1.6) | ||
| Gambled in the last 30 days | 0.367 | |||||
| Yes | 164 | 15.2 (1.3) | 94 | 13.5 (1.3) | −1.6 (−5.2, 1.9) | |
| No | 964 | 84.8 (1.3) | 664 | 86.5 (1.3) | ||
| Frequency of alcohol use | 0.043 | |||||
| Never/monthly or less | 785 | 76.3 (1.6) | 526 | 71.1 (1.8) | −5.1 (−9.8, −0.5) | |
| 2–4 times a month | 182 | 18.3 (1.4) | 135 | 20.4 (1.6) | 2.1 (−2.0, 6.3) | |
| 2 or more times a week | 53 | 5.4 (0.9) | 56 | 8.4 (1.1) | ||
Based on two‐sided χ2 (categorical variables). Benjamini and Hochberg's (BH) control for the false discovery rate approach was used to adjust for the multiple comparisons [38]. This was applied as follows: for each of the outcomes considered, the P‐values were sorted in an ascending order. For each test, if the obtained P‐value ≤0.05 × (i/n), where (i = 1 to n; n = 12), then it was considered statistically significant. For example, the first test was considered statistically significant if obtained P ≤ (0.05 × 1/12) or P ≤ 0.004.
All sample sizes are unweighted and might not add to the total because of missing observations; proportions, means and SE are weighted.
CI.
P < 0.05.
Prevalence of lifetime use of cannabis among males was 30% ± 2.2% in 2015 and increased to 36.1% ± 2.6% in 2022 (P = 0.073). The annual prevalence among males was 12% ± 1.5% in 2015 and 14.7% ± 1.9% in 2022 (P = 0.073). The number of female cannabis users was small (n = 29), precluding a meaningful comparison.
The proportion of respondents reporting that it was easy to obtain cannabis within 24 hours increased from 25% ± 1.7% in 2015 to 32.1% ± 1.9% in 2022. The proportion of those who found it impossible to obtain cannabis within 24 hours minimally decreased from 51.5% ± 2% in 2015 to 49.1 ± 2% in 2022. Relevant data tables with confidence intervals and standard errors are available in the Data S1. Distribution of demographic characteristics, tobacco and alcohol use, and gambling behavior by perceived difficulty to obtain cannabis within 24 hours and prevalence of cannabis use in 2022 are also presented in the Data S1.
After adjusting for covariates in the logistic regressions (see Table 3), we found that lifetime prevalence of cannabis use was similar in 2022 (18.1%) compared to 2015 (17.3%), P = 0.726. In 2022, it was easier to obtain cannabis within 24 hours (lower odds of ‘impossible’ (OR = 0.7; 95% CI = 0.5, 1.1) and ‘difficult’ (OR = 0.5; 95% CI = 0.4, 0.8) compared with easy; P = 0.021). Adjusted percentage of those responding that it was easy to obtain cannabis increased from 24.9% (95% CI = 21.0, 28.9) in 2015 to 32.5% (95% CI = 27.1, 37.9) in 2022. Age of first cannabis use was statistically significantly higher in 2022 than in 2015 (least square means [95% CI] = 19.1 [18.5, 19.8] vs. 18.1 [17.8, 18.4], P = 0.003) (data not shown).
TABLE 3.
OR and 95% CI and adjusted percentages and 95% CI from multivariable logistic or multinomial logistic regressions to evaluate whether lifetime and annual cannabis use and perceived difficulty to obtain cannabis within 24 hours changed from 2015 to 2022. a
| Cannabis use/perceived difficulty to obtain cannabis | OR (95% CI) | Adjusted percentage (95% CI) | ||
|---|---|---|---|---|
| 2022 vs. 2015 | P‐value | 2015 | 2022 | |
| Lifetime prevalence of use | 1.1 (0.7,1.6) | 0.726 | 17.3 (14.5,20.1) | 18.1 (14.3,21.9) |
| Annual prevalence of use | 1.1 (0.7,2.0) | 0.650 | 7.02 (5.2,8.9) | 7.7 (5,10.4) |
|
Difficulty to obtain within 24 hours Impossible vs. easy Difficult vs. easy |
0.7 (0.5,1.1) 0.5 (0.4,0.8) |
0.021* | Impossible | |
| 51.3 (46.9,55.7) | 50.4 (45,55.9) | |||
| Difficult | ||||
| 23.8 (20.1,27.5) | 17.1 (13.1,21.1) | |||
| Easy | ||||
| 24.9 (21,28.9) | 32.5 (27.1,37.9) | |||
Obtained from multivariable logistic regressions adjusted for sex (male, female); age (in years); education (primary/secondary, higher); occupation (employed, unemployed, student, pensioner [including social]); monthly income (≤500 Georgian Lari [GEL], >500 GEL, approximately USD$200 in 2015, USD$180 in 2022); alcohol use frequency (less frequently than once a month or never, once a month, 2–4 times a month, 2 or more times a week); and lifetime, 12‐month and 30‐day prevalence of gambling (yes, no).
P < 0.05.
Factors associated with cannabis use and perceived difficulty to obtain cannabis within 24 hours
Results from the multivariable logistic regressions to evaluate the association of the factors with lifetime and annual use using data from the 2022 survey suggested significant associations with lifetime prevalence of cannabis use were male sex (OR = 0.1; 95% CI = 0.1, 0.3), higher income (OR = 2.3; 95% CI = 1.1, 4.6), more frequent alcohol use (OR = 4.5; 95% CI = 2.0, 10.3) and gambling (OR = 2.81; 95% CI = 1.68, 4.71). Results for annual prevalence were similar to lifetime prevalence, but associations are based on a smaller sample size. Details on factors associated with cannabis use in the 2022 survey are presented in Table 4.
TABLE 4.
Adjusted OR and 95% CI, and adjusted percentages and 95% CI from multivariable logistic regressions to evaluate factors associated with lifetime and annual prevalence of cannabis use in the 2022 survey wave.
| Factors | Cannabis use | |||||
|---|---|---|---|---|---|---|
| Lifetime (n = 637) | Annual (n = 638) | |||||
| OR (95% CI) | P‐value | Adj. % (95% CI) | OR (95% CI) | P‐value | Adj. % (95% CI) | |
| Gender | <0.0001 | <0.0001 | ||||
| Male | Reference | 30.5 (25.2,35.8) | Reference | 13.1 (9.2,17.1) | ||
| Female | 0.1 (0.1,0.7) | 7.5 (4.0,10.9) | 0.1 (0.0,0.3) | 1.9 (0.1,3.7) | ||
| Education | 0.589 | 0.725 | ||||
| Primary/secondary | Reference | 21.0 (17.1,24.9) | Reference | 8.6 (5.8,11.3) | ||
| Higher | 1.2 (0.7,2.1) | 22.9 (16.8,29.1) | 1.2 (0.5, 2.4) | 9.5 (4.9,14.2) | ||
| Occupation | 0.094 | 0.34 | ||||
| Employed/self‐employed | Reference | 20.7 (15.5,25.8) | Reference | 8.0 (4.5,11.4) | ||
| Student | 0.6 (0.3,1.5) | 15.6 (8.3,22.9) | 0.2 (0.1,1.0) | 2.2 (−0.8,5.2) | ||
| Unemployed, social or pension | 1.6 (0.7,3.6) | 26.7 (19.5,33.8) | 2.5 (0.8,8.4) | 15.7 (7.3,24.2) | ||
| Income | 0.028 | 0.114 | ||||
| ≤500 GEL | Reference | 16.7 (11.6,21.8) | Reference | 5.9 (2.4,9.3) | ||
| >500 GEL | 2.3 (1.1,4.6) | 27.0 (20.6,33.5) | 2.7 (0.8,8.9) | 12.6 (6.5,18.6) | ||
| Alcohol use frequency | <0.001 | 0.209 | ||||
| Never/monthly or less | Reference | 16.3 (12.4,20.2) | Reference | 7.2 (4.2,10.2) | ||
| 2–4 times a month | 2.8 (1.3,4.0) | 27.3 (20.3,34.2) | 1.5 (0.7,3.2) | 9.8 (5.2,14.4) | ||
| 2 or more times a week | 4.5 (2.0,10.8) | 38.5 (25.3,51.7) | 2.4 (0.9,6.3) | 14.0 (5.7,22.3) | ||
| Ever gambled | <0.0001 | 0.003 | ||||
| No | Reference | 27.0 (22.4,31.6) | Reference | 11.7 (8.3,15.1) | ||
| Yes | 2.8 (1.7,4.7) | 14.1 (9.6,18.5) | 3.2 (1.5,6.8) | 4.4 (1.7,7.2) | ||
Males initiated cannabis use at an earlier age with a least squares mean of 19.1 years (95% CI = 18.6, 19.6) among males, compared to a least squares mean of 20.6 years (95% CI = 19.3, 21.9) at onset for females (P = 0.031). Those unemployed also started using cannabis at an earlier age, on average 17.8 years (16.9, 18.7) for unemployed compared to 20 (19.3, 20.7) years for employed and 19.6 (17.9, 21.2) years for students, (P = 0·003). Age of first use did not differ by level of education or income. In the 2022 survey wave, 59.4% (52.4, 65.4) of females said it would have been impossible to obtain cannabis within 24 hours if they wanted to, compared to 38.7% (32.4, 45.0) for males. Obtaining cannabis was perceived easy for 39.4% (33.1, 45.6) of males compared to 25.7% (20.1, 31.2) of females. Obtaining cannabis was also perceived as more difficult for those with the following characteristics: lower income; students that rarely or never drank alcohol; and did not gamble. We present regression results for perceived difficulty to obtain cannabis in Table 5.
TABLE 5.
Adjusted OR and 95% CI from multivariable multinomial logistic regressions to evaluate factors associated with perceived difficulty to obtain cannabis.
| Factors | Perceived difficulty to obtain cannabis within 24 hours | ||
|---|---|---|---|
| OR (95% CI) | P‐value | ||
| Impossible vs. easy | Difficult vs. easy | ||
| Gender | <0.0001 | ||
| Male | Reference | ||
| Female | 2.56 (1.62,4.06) | 1.07 (0.60,1.91) | |
| Education | 0.334 | ||
| Primary/secondary | Reference | ||
| Higher | 0.77 (0.47,1.27) | 0.64 (0.34,1.19) | |
| Occupation | 0.054 | ||
| Employed/self‐employed | Reference | ||
| Student | 0.49 (0.23,1.05) | 0.60 (0.26,1.39) | |
| Unemployed, social or pension | 1.00 (0.53,1.91) | 0.53 (0.23,1.19) | |
| Income | 0.724 | ||
| ≤500 GEL | Reference | ||
| >500 GEL | 0.78 (0.42,1.45) | 0.84 (0.40,1.74) | |
| Alcohol use frequency | <0.042 | ||
| Never/monthly or less | Reference | ||
| 2–4 times a month | 0.91 (0.52,1.58) | 0.60 (0.29,1.21) | |
| 2 or more times a week | 0.30 (0.12,0.72) | 0.41 (0.17,1.01) | |
| Ever gambled | <0.0001 | ||
| No | Reference | ||
| Yes | 0.39 (0.25,0.59) | 0.75 (0.44,1.27) | |
DISCUSSION
The country of Georgia legalized cannabis consumption and decriminalized cannabis possession in 2018, becoming one of the first countries in the world and the first in the region to do so. Rather than being based on a referendum or a parliamentary bill, legalization was based on a Constitutional Court ruling (a similar process led to cannabis decriminalization in South Africa later the same year) [39]. Restrictions on use by persons younger than 21, sale and distribution were retained. In this study, we measured the impact of the policy change on cannabis use among Georgian young adults using a repeated cross‐sectional design (population representative data collected in 2015 and 2022, before and after legalization). We identified a modest, but not statistically significant, increase in lifetime and annual prevalence of cannabis use. This modest increase in prevalence of use could possibly be explained by a greater willingness to disclose cannabis use following legalization, rather than a behavioral change. According to respondents' perceptions, obtaining cannabis became easier, yet it is unclear whether young adults had easier access to cannabis after 2018.
In theory, one could hypothesize that, following at least partial legalization, there was social normalization and acceptability of cannabis, reduced stigma, declining perceptions of harm and growing exposure to more potent and varying products. In the case of Georgia, it is unclear if any of these potential consequences ensued. Although the cannabis use policy change of 2018 was considered liberal, a major part of Georgian society and leadership (e.g. government, a significant part of political opposition and leading religious organizations) remain conservative with regards to cannabis legalization.
The cannabis use rates identified in our study among young adults were approximately twice as high as those reported among the population of 18 to 64 years old in the General Population Survey 2022 [36]. Prevalence of use among young males found in our study was also higher than the previously reported rates for people 18 to 64 years old in 2022. This suggests more prevalent use among younger adults, which is similar to the overall situation in Europe [40]. Cannabis use among females could be considerably under‐reported because of high stigma among women, but the stigma issue needs further research. In contrast to Georgia, a big data analysis from the United States (US) found that cannabis use was associated with lower annual income and educational attainment [41]. Educational attainment (e.g. college degree) inversely correlated with age of first use. In Georgia, cannabis use was initiated relatively late, at ~18 years of age before legalization and at 19 years of age after legalization [42]. This timing of initiation of cannabis use in Georgian young adults may have obviated a major impact on their educational attainment, at least through high school.
Past year prevalence of cannabis use found in this study among young adults (18–29 years old) in 2022 (8.5%) was similar to the European average of 8% for all ages, but much lower than the European average of 15.1% among those 15–34 years old and 18.2% for those 15–24 years old. Furthermore, use in the last month in our sample (4.1%) was lower compared to the European average among those 15–24 years old (9.6%) [40]. Past year cannabis use prevalence observed in Georgia in 2022 was similar to that reported in Cyprus, Latvia and Lithuania. Unlike in Georgia, cannabis use in these countries can lead to incarceration. Past month cannabis use prevalence was similar to that reported in Cyprus, Latvia, Poland and Slovakia. We could not find similar measures from neighboring countries to compare (any cannabis use in all the neighboring countries is illegal). In Georgia, the age of initiation increased after legalization. Better understanding of these processes would need further survey waves and qualitative explorations, particularly considering mixed findings from other contexts [13, 43, 44].
Effects of liberalization are difficult to measure, compare and generalize across countries because of major differences in country contexts, legal base and other factors. To date, findings on effects and impact of recreational cannabis legalization and decriminalization on societies have been inconsistent and disproportionately focused on certain jurisdictions. Most of the literature exploring effects of legalization and decriminalization on recreational use comes from the United States and Canada, where baseline proportions of use were much higher than in Georgia in 2015. A longitudinal study from California, the first state to legalize cannabis in 1998, reported no overall significant change in frequency of cannabis use among young adults (18–24) following legalization in 2018 [45]. Another longitudinal study, from Canada, identified reduction in use among young adults who used cannabis often before legalization, with only a minor increase among survey individuals who had no pre‐legalization use. Overall, they did not identify changes in cannabis‐related consequences [28]. Relatively low frequency of use, which remained quite stable after 2018, as identified in our study from Georgia, suggests that there were no widespread cannabis‐related poor health outcomes. However, broader public health implications such as changes in demand for related psychiatric and mental health services, emergency care or motor‐vehicle crash‐related trauma are some important unexplored topics. We observed that tobacco smoking and use of other illicit substances became less prevalent among the same population in Georgia. International evidence of whether recreational cannabis use legalization increases or decreases use of other substances remains divided [10]. Decrease in other substance use could be explained by an increase in prices for other drugs [46].
Limitations
This was a repeated‐cross sectional study of self‐reported data, which has limited power to identify causality and the impact of cannabis legalization on people's behavior, despite adjustment for a number of potential confounders. Under‐reporting is a possibility, particularly in 2015 when cannabis use was punishable under criminal law and respondents could hesitate to disclose use because of fears of prosecution. These estimates should be considered conservative [37]. Possibly, respondents in the 2022 survey were more open to disclose use because cannabis use and related perceptions became more normalized after decriminalization. Another possible measurement error could be reporting error, particularly for retrospective variables such as age of first cannabis use. Considering the separation of data collection points by 7 years, history effect should be considered as a limitation.
Legalization's short‐term and long‐term effects on the cannabis market would differ [10, 26, 27].
Liberalization in most of the countries and territories is still too recent to have examined the behavioral and societal effects. In different contexts, cannabis use liberalization policy changes (including legalization for medical use only) have varying effect on perceptions, acceptability and recreational use and, therefore, require close scientific monitoring [29, 30]. An important factor that was not adjusted for is the coronavirus disease 2019 (COVID‐19) pandemic, which could affect cannabis use [19, 47, 48, 49, 50]. Georgia went through long periods of stringent COVID‐19 restrictions resulting in prolonged isolation and significant economic impact [51]. Some decrease of cannabis use and increase in prices in the first months of the COVID‐19 pandemic was reported in Europe [47]. A study from Georgia reported decrease in cannabis use among people who use substances during the first months of the COVID‐19 pandemic [19]. University students in Georgia reported very high rates of depression and anxiety during a COVID‐19 lockdown, with the students reporting lower substance use having less depression and anxiety [52]. People use cannabis to address mental health impacts of isolation, such as depression or boredom [53, 54]. However, such factors as restrictions of public gatherings (and cannabis is often used in groups at parties) and increased difficulty obtaining cannabis, could result in its decreased use. It is difficult to ascertain if there would be rapid rebound or not [54, 55]. We did not assess availability or accessibility change (e.g. price) on the black market, whereas such a change could also affect use. We did not have data on quantity of cannabis used, which is a parameter different from the prevalence or frequency of use. Quantity could be a clinically relevant factor to measure regarding a change in cannabis use as a potential consequence of legalization.
Policy implications and further research needs
Despite research progress, questions about recreational cannabis use legalization effects on societies remain, and further multidisciplinary studies from various policy environments and contexts could inform the pursuit of the optimal policy. Studies from various contexts and environments guide policy making, educational and public health interventions and bring the international community closer to the best formula of recreational cannabis liberalization. Georgia is a relatively unique country in which to carry out such an examination. Our findings suggest that legalization, as it transpired in Georgia, could be a useful example of a balance between public liberty (rights to execute own will [i.e. use cannabis]) and public health interests. Legalization provides an opportunity for strict regulation and control. As long as cannabis retail remains illegal and production unregulated, it will not be possible to eliminate the illicit market, control the uptake (and minimize uptake among youth) and quality of the products (now distributed through personal contacts and on the illicit market), therefore, to some extent counterbalancing the potential public health benefit of keeping prevalence of use low. Relatively higher rates of use among youth underscore the importance of ongoing close attention and periodic monitoring among youth, who are also more vulnerable to the adverse health and developmental effects of cannabis [3, 56]. The effects of policy change on the studied parameters should be considered as up to the survey time (2022) and not as final. The acute and chronic health effects could be further delayed. Additional policy changes should not be ruled out. In Georgia, further survey waves (e.g. the General Population Survey) are needed to identify long‐term changes and health effects. Future waves ideally, although comparable to the first two surveys, should also include questions about the amount of cannabis used and ways to obtain cannabis. The surveys could also ask additional questions: how young adults obtain and use cannabis; what are the key reasons for cannabis use; how their experiences and perceptions of stigmatization impact their decisions on use; what is their awareness and perceptions of mental and physical health consequences, and the social and legal risks of cannabis use. Perceived harmfulness changes could impact decisions and patterns of use [57]. We also recommend longitudinal studies, particularly in high‐risk groups (e.g. youth who use cannabis with alcohol, cannabis use and gambling), and studies measuring potential negative consequences of cannabis legalization (e.g. analyzing data on mental health services and emergency visits), crime and illicit market analyses and surveillance of CUD in the country. Furthermore, it is important to conduct research among an even more vulnerable population group—teenagers (13‐ to 17‐year‐olds).
CONCLUSIONS
This population‐representative study suggests that cannabis use among young adults in Georgia did not increase following legalization of recreational cannabis use (whereas retail and public use remained restricted) and decriminalization of limited possession (for personal use) of cannabis in the country. Age of first use increased significantly. Despite retail restrictions, the perception among young adults was that it became easier to obtain cannabis. Cannabis use is much more common among males, who also start cannabis use at an earlier age and obtained cannabis more easily compared to females. Cannabis use in Georgia was associated with gambling, tobacco smoking, alcohol use and higher income. The effects of policy change on the studied parameters should be considered as up to the survey time (2022) and not as final. The effect on population health could be further delayed.
Recreational cannabis use legalization, as implemented in Georgia, could be a useful example of balancing public liberty and public health interests. Studies from various contexts and ecosystems are required to guide further policy making, educational and public health interventions and bring the international community closer to the best approach to transitioning to recreational cannabis use.
AUTHOR CONTRIBUTIONS
Ilia Nadareishvili: Conceptualization (lead); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal); project administration (supporting); visualization (supporting); writing—original draft (lead). Sowmya R. Rao: Conceptualization (supporting); formal analysis (lead); investigation (equal); methodology (equal); software (lead); validation (equal); visualization (lead); writing—original draft (supporting). David Otiashvili: Conceptualization (equal); data curation (equal); formal analysis (supporting); funding acquisition (equal); investigation (equal); methodology (equal); resources (equal); validation (equal); writing—original draft (supporting). Natalia Gnatienko: Conceptualization (equal); formal analysis (supporting); funding acquisition (equal); investigation (equal); project administration (lead); resources (equal). Jeffrey H. Samet: Conceptualization (equal); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal); resources (equal); supervision (equal); validation (equal); visualization (supporting); writing—original draft (supporting). Karsten Lunze: Conceptualization (lead); formal analysis (equal); funding acquisition (lead); investigation (equal); methodology (equal); project administration (supporting); resources (supporting); supervision (equal); writing—original draft (supporting). Irma Kirtadze: Conceptualization (equal); data curation (lead); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal); supervision (equal); writing—original draft (supporting).
DECLARATION OF INTERESTS
None.
Supporting information
Data S1. Supporting Information.
ACKNOWLEDGEMENTS
We thank Sally Bendiks and Aleksandre Tskitishvili for their contribution to the manuscript. This study was supported by National Institutes of Health, National Institute on Drug Abuse, NIDA International INVEST fellow award (IN). The primary studies in 2015 and 2022 were supported by European Monitoring Center for Drug and Drug Addiction (CT.21.EMCDDA4GE.0112.1.0), United States Agency for International Development (USAID) and Czech Development Agency (CzDA).
Nadareishvili I, Rao SR, Otiashvili D, Gnatienko N, Samet JH, Lunze K, et al. Post‐legalization shifts in cannabis use among young adults in Georgia—A nationally representative study. Addiction. 2025;120(2):335–346. 10.1111/add.16688
Funding information European Monitoring Center for Drug and Drug Addiction, Grant/Award Number: CT.21.EMCDDA4GE.0112.1.0; United States Agency for International Development (AID‐114‐A‐00007) and Czech Development Agency (CzDA‐GR‐GE‐2014‐43081); National Institutes of Health, National Institute on Drug Abuse; 2023 and 2024 National Institute on Drug Abuse International Visiting Scientists and Technical Exchange Program Drug Use and Addiction Research Fellowship.
Karsten Lunze and Irma Kirtadze contributed equally to this work.
Footnotes
In Georgian context, homemade stimulants are injectable solutions of amphetamine or methamphetamine produced by individuals who use substances through reduction or oxidation of ephedrine or pseudoephedrine.
DATA AVAILABILITY STATEMENT
All of the de‐identified individual participant data used in this study will be made available to Researchers who provide a methodologically sound proposal upon a formal request and agreement. The data can be used to achieve aims in the approved proposal. Proposals should be directed to irma@altgeorgia.ge; to gain access, data requestors will need to sign a data access agreement.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data S1. Supporting Information.
Data Availability Statement
All of the de‐identified individual participant data used in this study will be made available to Researchers who provide a methodologically sound proposal upon a formal request and agreement. The data can be used to achieve aims in the approved proposal. Proposals should be directed to irma@altgeorgia.ge; to gain access, data requestors will need to sign a data access agreement.